A 10-year-old child was admitted with full-thickness burns affecting more than 15% of the child’s body surface. What manifestations of hypovolemic shock would you observe for over the next 48 hrs? Select all choices that apply:

Rapid pulse.

Decreased B/P.

Pallor.

Flushed Face.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale
Rapid pulse is a common manifestation of hypovolemic shock. When the body experiences a significant loss of fluid, such as in severe burns, the heart rate increases in an attempt to maintain adequate blood flow and oxygen delivery to the body’s tissues.
Choice B rationale
Decreased blood pressure is another typical sign of hypovolemic shock. As the body loses fluid, the volume of blood circulating through the body decreases. This drop in blood volume leads to a decrease in blood pressure.
Choice C rationale
Pallor, or paleness of the skin, can occur in hypovolemic shock. This happens because the body prioritizes sending blood to vital organs like the heart and brain, which can result in less blood flow to the skin, causing it to appear pale.
Choice D rationale
A flushed face is not typically associated with hypovolemic shock. In fact, the skin may actually appear pale or cool due to reduced blood flow.

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Correct Answer is B

Explanation

Choice A rationale
A 2+ right pedal pulse indicates a normal pulse and is not a cause for immediate concern in a child with a femur fracture.
Choice B rationale
Tingling in the right foot could indicate nerve damage or compromised blood flow, which can be a serious complication of a femur fracture. This should be the nurse’s priority as it could lead to long-term damage if not addressed promptly.
Choice C rationale
A capillary refill time of less than 2 seconds is considered normal and is not a cause for immediate concern in a child with a femur fracture.
Choice D rationale
A respiratory rate of 24/min is within the normal range for a school-age child and is not a cause for immediate concern in a child with a femur fracture.

A. Bend forward from the waist with your head and arms downward. B. Touch your chin to your chest, and then look up at the ceiling. C. Lie prone on the examination table. D. Turn to the side and remain in a relaxed position.

Correct Answer is A

Explanation

Choice A rationale
Bending forward from the waist with the head and arms downward, also known as the Adams forward bend test, is the standard screening test for scoliosis.
Choice B rationale
Touching the chin to the chest and then looking up at the ceiling does not provide a view of the spine necessary for scoliosis screening.
Choice C rationale
Lying prone on the examination table is not a standard position for scoliosis screening.
Choice D rationale
Turning to the side and remaining in a relaxed position is not a standard position for scoliosis screening.

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A 10-year-old child was admitted with full-thickness burns affecting more than 15% of the child’s body surface. What manifestations of hypovolemic shock would you observe for over the next 48 hrs? Select all choices that apply:

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a school-age child who has a fracture to the right femur. Which of the following findings is the nurse’s priority?

Correct Answer is B

Explanation

A school nurse is screening an 11-year-old child for idiopathic scoliosis. Which of the following instructions should the nurse give the child for this examination?

Correct Answer is A

Explanation

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